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Management of Common Conditions In General Practice including the “red made easy”

© Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care University of Auckland, Tamaki Campus

Reviewed by Hon A/Prof Amanda Oakley - 2019

http://www.dermnetnz.org

Management of Common Skin Conditions In General Practice

Contents Page Derm Map 3 Classic location: & children 4 Classic location: adults 5 terminology 6 Common red 7 Other common skin conditions 12 Common viral 14 Common bacterial infections 16 Common fungal infections 17 Arthropods 19 Eczema/ 20 Benign skin lesions 23 Skin cancers 26 Emergency dermatology 28 Clinical diagnosis of 31 Principles of diagnosis and treatment 32 Principles of treatment of eczema 33 Treatment sequence for 34 Topical 35 Combination topical + antimicrobial 36 Safety with topical corticosteroids 36 Emollients 37 Antipruritics 38

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2 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice DERM MAP

Start Is the patient sick ? Yes Rash could be an or a ? No Insect Bites – Crop of grouped with a central or scab. Is the patient in pain or the rash Yes Infection: / erysipelas, , is swelling, oozing or crusting? / , / zoster. Urticaria – Smooth skin surface with weals that evolve in minutes to hours. No

Is the rash in a classic location? Yes See our classic location chart . – Papular rash trunk and limb; burrows in-between fingers and on wrists.

No Yes Does the rash have a smooth surface? Eczema / Dermatitis – Localised or generalised rash with several clinical patterns. Is the rash very itchy?

Yes Does the rash have a rough or blistered – Salmon pink surface? plaques that are thin and indistinct. Not always

Psoriasis – Symmetrical plaques that are Yes Does the rash have a diffuse scale? thickened and distinct. Is the rash scaly, but not usually itchy? Tinea Infections – Slowly growing Yes Does the rash have a peripheral scale? asymmetrical plaques; positive mycology.

No If diagnosis is obscure, consider swabs, Rosea – Herald patch then smaller Yes scrapings, , referral; trial of moderate oval plaques along Langer’s lines on upper potency and emollients. None of these? trunk.

3 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

Classic Location Chart: Infants and Children

4 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

Classic Location Chart: Adults

5 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

DERMATOLOGY TERMINOLOGY Typical definitions of descriptive terms for skin lesions are given here but are not universally accepted.

PRIMARY LESIONS: Macule Small flat area of changed colour, any shape (usually < 10 mm). Patch Flat or flattish area of textural change > 10 mm, any shape. Can be scaly. Solid, elevated lesion < 10 mm in diameter. Plaque Elevated flat-topped lesion usually > 10 mm in diameter; may be composed of confluent papules. Nodule Solid lesion > 10 mm in diameter, often elevated and arising from or subcutaneous tissue. Tumour Benign or malignant growth of tissue. Vesicle Fluid-filled cavity < 10 mm (small blister). The fluid can be clear, serous or haemorrhagic. Umbilicated (depressed centre) if viral origin. Bulla Fluid-filled cavity > 10mm (large blister). May be intraepidermal or subepidermal. Pustule Superficial, white or yellow pus-filled cavity containing neutrophils; may be follicular or non-follicular, infected or non-infected. Collection of pus in a cavity formed by necrotic tissue. Weal Transient, elevated lesion caused by localised oedema (hive), without surface change, and any shape. Indicates urticaria or urticaria-like condition. Cyst Fluctuant fluid- or semi-fluid filled closed cavity.

SECONDARY LESIONS: These result either from the natural evolution of primary lesions (e.g. a vesicle bursts resulting in an erosion) or from the patient’s manipulation of the primary lesion (e.g. scratching resulting in an erosion).

Scale Flakes of the horny epithelium, often accompanied by another descriptive term e.g. ‘silvery’, ‘like sandpaper’. (scab) Dried serum, blood, or pus; thin and friable or thick and adherent. Yellow, brown, purple or black in colour. Excoriation A linear, punctate or hollowed-out area, caused by scratching, rubbing, or picking. Lichenification Thickened plaque due to rubbing, resulting in accentuated skin markings and adherent scale. Erosion Loss of part or all of the ; heals without scarring. Shallow moist or crusted lesion. Loss of epidermis, at least part of the dermis, and may involve subcutis; heals with scarring. Scar Fibrous tissue or collagen replacing normal skin structures after destruction of some of the dermis. Permanent.

The shape of skin lesions may be linear, annular or arcuate or grouped. Distribution may localised or generalised. 6 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON RED RASHES – localised or widespread change in skin appearance or texture CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT +/- neck, Non-inflammatory Typical site. None. Mild: antiseptic or cleanser, chest and back. comedones Mixture of lesions. cream/gel applied to (blackheads and all areas affected. Can add topical whiteheads) and but these should not be inflammatory follicular prescribed alone. papules, Moderate: topical (applied pustules +/- nodules and sparingly to all areas affected areas at cysts. night), oral tetracycline (doxycycline), combined OCP +/- Persistent: oral (requires Special Authority application). Severe: start antibiotics and refer to dermatologist. Bacterial Anywhere, Pain and/or and/or Pain and/or moist yellow Swab if moist or Topical antiseptic (e.g. hydrogen infection especially face redness. enlarging plaques antibiotics have peroxide cream) short-term if minor (impetigo), (impetigo), follicular failed. only, oral in most cases, limbs (). pustules (boils). consider IV if patient sick; incise and drain where relevant; refer when relevant. Drug eruption Anywhere, Many different patterns. New drug (1 to 3 Careful history Consider non-drug cause e.g. viral especially trunk. Most often, widespread weeks). (prescribed and infection esp. URTI symptoms & minor morbilliform (measles-like) Clearance on stopping OTC drugs, lesions within mouth. rash +/- fever +/- . drug (may take several vitamins, Stop drug. Urticaria next most weeks). herbals). Emollients, topical steroid creams. common morphology. Arrange urgent admission if sick patient (fever, mouth ulcers, , other organ involvement). Eczema Anywhere – Intensely itchy papules or Itch + location + surface Skin swabs for Non-soap cleanser. (see page distribution plaques. dryness / blistering. bacteria and herpes Emollients ++. 20 to 22) depends on Acute eczema is red and Clears rapidly with simplex, if secondary Intermittent topical steroid. specific condition, blistered. appropriate strength infection not clearing See page 33 and 34, 35 to 38 age and cause. Chronic eczema is dry topical steroid. with antibiotics. and thickened.

7 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON RED RASHES – localised or widespread change in skin appearance or texture CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Fungal Anywhere – One or more Slowly enlarging or Skin scrapings for If typical or once diagnosis confirmed, infection esp. toe clefts. asymptomatic to fluctuating plaques. mycology. topical and/or oral agent. Stop (see page moderately itchy irregular Asymmetrical any topical in use if 17 and 18) plaques, prominent distribution. mycology positive. peripheral scale / maceration. Herpes Lips, genitals, face, Acute eruption of irritable Blisters recur at same Early swab of base of Mild: none, or topical aciclovir. simplex around nails vesicles that crust in a few site from time to time, blister for viral culture Severe: oral aciclovir 200-400 mg (herpetic ) or days. Fever and especially with URTI or and PCR. 5x/day or valaciclovir 500 mg 2x/day x 5 anywhere. lymphadenopathy in when ‘run down’. days.Frequent recurrences: long term primary infection. aciclovir 400 mg bd or valaciclovir 500 mg od. Herpes Dermatomal. Pain precedes Pain; dermatomal Early swab of base of Oral aciclovir 800 mg 5x/day or zoster Unilateral. and vesicles that become distribution of eruption. blister for viral culture valaciclovir 1 g 3x/day for 7days. Start crusted; eruption clears in Recurrence is rare. and PCR. even if diagnosis uncertain, especially if 3 weeks but neuralgia may >60 years. persist for months. Refer urgently to ophthalmology if eye involvement (nasociliary branch of CV1). Amitriptyline for neuralgia.Capsaicin cream for chronic neuralgia. Body folds: Irritant/psoriatic type: well- Typical site. Swab for candida and If candida, topical antifungal. under breasts, demarcated moist other organisms. If irritant or mixed, topical antifungal + , erythema. Often chronic. . abdominal apron. Candida: satellite pustules, usually acute. Itch Anywhere, localised Careful skin and general Burrows – scabies. If no primary lesion: If no primary lesion: trials of emollients, area to whole body. examination. Look for Dry skin – eczema. CBC, LFT, TFT, renal low potency topical steroid, oral primary skin lesions; Vesicles on elbows and function, iron studies, and/or tricyclic excoriations are non- knees – dermatitis CXR. antidepressants. specific. herpetiformis. Anti-itch cooling cream 0.5% camphor, Shifting sites – urticaria. 0.5% menthol in emollient base. No primary lesion – Refer to dermatology for phototherapy. neuropathic or systemic origin.

8 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON RED RASHES – localised or widespread change in skin appearance or texture CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Keratosis Upper arms; Numerous longstanding Location and None. No treatment is usually indicated or pilaris sometimes scaly follicular papules, appearance. effective. anterior thighs which may be skin Non-soap cleansers, emollients, and coloured, red or brown. exfoliation and topical retinoid may lateral cheeks. improve appearance temporarily. Periorificial Mid-face: Irritable clusters of slightly Adult female 20 to 40 None. Stop applying face creams. dermatitis around mouth, scaly papules and years. Counsel against the use of topical (perioral around nostrils erythematous plaques. Good response to (may require lower strength dermatitis, and around Associated with the use of tetracycline. product intermittently for 2 weeks). periocular eyelids. topical corticosteroids and Mild: azelaic acid cream or dermatitis) Rarely, may moisturisers. gel or nothing. affect skin Severe: 6 to 12-week course of around anus doxycycline 50 –100 mg daily. and vagina. Pityriasis Trunk, Initial larger herald patch ‘Fir tree’ distribution of serology in at No treatment is required for the majority, rosea proximal limbs. followed in days by many plaques in adolescent or risk patients, as who are asymptomatic. Non-soap oval plaques with scaly young adult. secondary syphilis cleansers, emollients and mild topical edge following natural skin may look similar but steroids for itch. cleavage lines (Langers tends to involve If severe pruritus, consider referral for lines). palms, soles and UVB phototherapy. Plaques persist for 6 to 12 mucosae. Those with Erythromycin 250 mg qid for 2 weeks weeks. syphilis will feel can be used (limited evidence). Itch may be absent, mild unwell and have Anecdotal reports of benefit from high or severe. lymphadenopathy. dose aciclovir (400 mg 5x/day for 7 days). Psoriasis Chronic: , Well-demarcated red scaly Involvement of scalp. None. Topical calcipotriol/ extensor knee, plaques. Symmetrical distribution. diproprionate ointment od for 4 weeks elbow, flexures Various subtypes. Prominent scale. (gel for scalp which can also be used on or anywhere. Fairly resistant to topical trunk and limbs). Not for face or genitals Acute guttate: therapy. Emollients. many small Tar cream for scalp. plaques on Refer if >10% body surface area for trunk. phototherapy, methotrexate, acitretin, biologics. See page 38

9 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON RED RASHES – localised or widespread change in skin appearance or texture CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Mid-face: Erythema, Celtic origin aged over 30 None. Non-soap cleaners. , cheeks, nose, chin. papules, with a red face and Mild: topical or pustules and sensitive skin. azelaic acid 2x/day. . Good response to Moderate/severe: doxycycline May involve eyelids. tetracycline. for 6 to 12 weeks, repeated as and when necessary. Minimise facial creams. Vascular laser or intense pulsed light (IPL) for persistent erythema and telangiectasia. Scabies Whole body except Burrows in web spaces and Nocturnal itch++. Dermoscopy Careful application of insecticide scalp/face. wrist creases. Polymorphic eruption reveals mite as to the entire body, reapply if any Babies: prominent on palms Excoriations trunk and (may resemble eczema, grey triangle at area washed e.g. fingers. and soles, may involve face. limbs. urticaria, insect bites). end of burrow. Treat all family members on Nodules in axillae/. Penile papules. If skilled in same occasion. Several family members extracting mites, Permethrin cream or lotion, affected. microscopy of wash off after 8 to 14 hours. burrow may Repeat in 1 to 2 weeks. reveal mite and Malathion lotion, wash off after eggs. 24 hours. Avoid in infants less than 6 months of age. If still symptomatic in one month, review and retreat if still infested. Treat secondary impetigo / eczema. Oral ivermectin may be appropriate for institutional and crusted scabies (apply for Special Authority funding) but may be less effective than topical insecticides in co- operative patients with classic scabies

10 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON RED RASHES – localised or widespread change in skin appearance or texture CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Actinic Sun exposed Multiple flat or Scale is adherent, feels like Biopsy if considering SCC, Cryotherapy, curettage and cautery, keratoses regions especially indurated, scaly, skin sandpaper grit. May sting or be especially if enlarging, indurated, excision. Topicals useful on scalp, , bald scalp, ears, coloured or reddened tender. tender or resistant to treatment. face but unsightly during treatment: 5- face, hands; less papules or small fluorouracil cream 2x/day for 2 to 4 often, also plaques. Cutaneous weeks, imiquimod 2 to 3 times weekly forearms, lower horn. for 4 to 12 weeks, ingenol mebutate legs. 0.015% gel daily for 3 days. Supervise treatment. Seborrhoeic Scalp, , ill-defined Flaking is prominent, not much itch. Swabs if secondary infection. Avoid thick face creams. dermatitis , flaking and erythema. Scrapings in case of tinea, if , or tar (see also upper eyelids, Often flares with stress causing bald areas or if hair can for scalp and other affected areas twice section on nasolabial folds, or for unknown be extracted easily. weekly. Ketoconazole or ciclopirox or eczema chest, reasons. is associated with other cream as required. page 20 and . seborrhoeic dermatitis but rarely Intermittent topical steroids: 22) reported by laboratory. hydrocortisone for face, moderate potency for scalp. // cream prior to shampooing. Urticaria Anywhere. Transient red itchy No surface change. Usually no tests are indicated. Non-sedating oral , e.g. superficial weals Individual weals disappear in Take a careful history to loratidine or cetirizine 10–20 mg once or (urticaria) and/or pale minutes (physical urticaria) to hours elucidate cause (especially in twice daily. painful deeper (spontaneous urticaria). acute cases): allergy or more swellings In most cases, good response to often non-immunological, (angioedema). oral antihistamines. including infection (40% acute cases), drug, food ( <1%) and autoimmune (most chronic cases). Angioedema without urticaria may be due to C1 esterase inhibitor deficiency (rare) or drug reaction (esp. NSAIDs and ACEI). Grover On the central Often rapid onset of Clinical Biopsy, which shows Keep skin cool, 1% hydrocortisone, back, mid chest small red, crusted (separated skin moisturisers with menthol or camphor as and occasionally spots (papules); can be cells) with or without anti-pruritic. elsewhere very itchy or (abnormal rounded asymptomatic. skin cells). 11 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

OTHER COMMON SKIN CONDITIONS CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Angular Oral Erythema, maceration, crusts and Site. Swab for Staph Topical antibiotic/antifungal/steroid cheilitis commissures. fissures. aureus, Candida mixture for up to 7–day courses. albicans and Regular sterilisation of dentures – Herpes simplex. consult dentist if poorly fitting. Consider general health. Aphthous Mouth, Round or oval very tender 1-10mm Recurrent nature, pain Biopsy if ulcer Analgesic mouthwash. ulcer tongue and yellow ulcers. and location. persistent and/or Bonjela gel (choline salicylate). mucosal indurated. in dental paste; silver surface of nitrate to cauterise lesion. lips. Sometimes vulva. Blisters Anywhere. Consider common causes: friction, Palms – scabies. Swabs for Staph. Drain big blisters, otherwise protect infection, insect bites, contact Grouped lesions with aureus and and leave intact. dermatitis, . central punctum – insect herpes. Potent topical steroids. bites. Biopsy small Review - if extensive, or patient Linear – plant contact. fresh blister. unwell, refer acutely. Elderly, mainly flexural – bullous pemphigoid. Most often Shedding: or drug or Distinguish shedding from Scraping if scaly. Oral antifungal required for scalp. systemic disease. balding. Punch biopsy if confirmed . Smooth bald patches: . Evaluate scalp for skin inflamed or Treatment is fairly ineffective for Slow thinning: pattern alopecia. disease. scarred. most types of alopecia. Scarring: inflammatory skin disease Thyroid function Long-term and topical ( erythematosus, lichen and iron studies each result in significant planopilaris, ). if diffuse thinning benefit in about 30 to 50% men with Scaly plaques: tinea capitis (children), and poor quality early male pattern balding. or hair pulled out because of psoriasis / hair. seborrhoeic dermatitis (older age group).

12 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

OTHER COMMON SKIN CONDITIONS CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Sun-exposed Maximal 8 hours after exposure. Pain, distribution and None in most cases. If seen before peak, NSAID and sites. Painful erythema, oedema and timing. If symptoms arise topical steroid. blistering confined to exposed areas. after minimal Otherwise, liberal emollients, cool exposure, consider baths, rest and analgesia. causes of photosensitivity including drugs. Face, neck, Symmetrical expanding areas of Smooth, white. If pale areas are Early use of potent topical steroid for skin folds or . scaly, do skin one to three months (pulse anywhere. scrapings (pityriasis treatment with on face versicolor) and in flexures). Sun protection.

13 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON VIRAL INFECTIONS – swab oozy or crusted skin lesions CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS (optional) Hand, foot and Hands, feet, oral Flat, often linear painful or Small child. Swab blister in viral Reassurance. mouth disease mucosa. painless blisters, mild fever. Outbreak in family or transport media for Fluid diet as required. Uncommonly, also day-care setting. enterovirus PCR. Antiseptic mouthwash. limbs. if required. Herpes Lips, face, genitals, Acute eruption of irritable Blisters recur at Early swab of base of Mild: none, or topical aciclovir. simplex around nails vesicles that crust in a few same site from time blister in viral transport Severe: oral aciclovir 200 mg (herpetic whitlow) days. to time, especially media for PCR. 5x/day or valaciclovir 500 mg or anywhere. Fever and lymphadenopathy in with URTI or when 2x/day x 5 days. primary infection. ‘run down’. Frequent recurrences: long term aciclovir 400 mg bd or valiclovir 500 mg od. Herpes zoster Unilateral Pain precedes erythema and Pain and dermatomal Early swab of base of Oral aciclovir 800 mg 5x/day or dermatomal. vesicles; these crust in 10 distribution of blister in viral transport valaciclovir 1 g 3x/day for 7days. days. Eruption clears in 3 eruption. media for PCR. Refer urgently to ophthalmology if weeks but neuralgia may eye involvement (nasociliary persist for months. branch of CV1). Molluscum Axillae and groin. Clusters of skin coloured or Location, typical None. Depends on age – reassurance contagiosum pink umbilicated soft 2 to 5 mm appearance, may be sufficient. papules that persist for weeks surrounding eczema. Individual lesions may be to months. squeezed or scraped out. May have surrounding dry skin Hydrocortisone cream for itch (but or eczema. it may not clear the rash). Some lesions may be scabbed Cautious application of salicylic or crusted. acid paint to papules every Can occur in adults. few days (apply plaster to avoid irritating other skin sites). Cryotherapy in older children and adults.

14 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON VIRAL INFECTIONS – swab oozy or crusted skin lesions CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT (optional) Viral Anywhere, Single or many warty Presence of thrombosed None. Salicylic acid paint or gel or plaster, daily for especially hands tender chronic papules or capillaries on removing 12 weeks – pare down surface skin prior to and feet. plaques (many variants). surface skin with blade and application, cover with tape. shows speckling Cryotherapy in older children and adults, to a few lesions, repeated every 3 to 4 weeks on 3 to 4 occasions (painful and not very successful for plantar warts). Genitals, Clusters of soft papules or Irregular but bilateral Cervical smear. Podophyllotoxin bd for 3 days (not in perianal. ‘cauliflower’ appearance. distribution. ). Distinguish from cancers, Imiquimod (inflammatory). which are firm or hard and Cryotherapy weekly. may ulcerate. Diathermy to larger solitary lesions. Consider referral to sexual health clinic.

15 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON BACTERIAL INFECTIONS – swab oozy or crusted skin lesions CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS (optional) Acute fold. Very tender red nail Pain; blisters suggest Swab for staph / strep. Mild: topical antiseptic + soaks e.g. povidone fold, sometimes pus. herpes simplex iodine ointment, solution, wash. (see above). More severe: flucloxacillin for 5 days. Boils and Centred on Painful inflamed Very tender red If persistent swab for 1st flucloxacillin or cephalexin 7 days. carbuncles hair follicle, follicular lesion or nodules. Staph. aureus and 2nd erythromycin or cefaclor 7 days. (furunculosis) anywhere. abscess. Carbuncle May contain pus. consider MRSA. Recurrent: topical antiseptics e.g. povidone has multiple heads. iodine ointment, solution, wash to nose, repeat Often recurrent in antibiotics when boils present, add intermittent different sites. rifampicin (requires specialist approval). If MRSA, lab sensitivities should guide choice of antibiotic, e.g. cotrimoxazole, erythromycin, doxycycline. Cellulitis and Lower leg or Spreading painful Fever, unilateral Swab / blood culture R/O osteomyelitis, septic arthritis. erysipelas anywhere. erythema and spreading erythema, for haemolytic 1st penicillin (strep) or flucloxacillin or cephalexin swelling, often wound lymphangiitis, streptococcus and (to cover staph) - 5 to 10 days. infection. lymphadenopathy. Staph. aureus 2nd erythromycin. Frequently febrile. Erysipelas is Early referral for IV antibiotics (e.g. cefazolin) + superficial and may oral probenecid in sick patient or if no result in blistering. improvement within 24 hours. Local hospital may have specific protocol for community IV tx to reduce need for admission. Folliculitis Centred on Acute or chronic Follicular pustules. Swab for Staph. Mild: topical antiseptics as for acne. hair follicle. follicular superficial aureus, yeasts (irritant More severe: flucloxacillin for 7 days. pustules. folliculitis is sterile). Persistent: doxycycline for 6 weeks. Impetigo Anywhere. Multiple yellow, Moist yellow enlarging Swab for Staph. If simple, hydrogen peroxide cream; if May crusting or blistered plaques. aureus and/or S extensive/fever/lymphangiitis, oral antibiotics complicate plaques. pyogenes. (flucloxacillin or cephalexin). Minimise use of eczema, insect Consider MRSA. topical mupirocin and fucidin to reduce bites, scabies. development of antibiotic resistance. Ingrown Usually on Painful lump on side Location and pain. Swabs not usually Elevate corner of toenail with cotton wool. toenail lateral border of big toenail. helpful, but may If persists then remove side of nail or do wedge of big toe. culture Staph. aureus. resection. If severe, oral flucloxacillin.

16 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON FUNGAL INFECTIONS – scrape peeling or scaling skin for mycology CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT (Scrapings/clippings are essential) Chronic One or more Swollen red tender nail Affects those with cold fingers or wet Swab for Candida Topical + topical paronychia nail folds. folds, sometimes pus under environment. albicans steroid cream if evidence for cuticle, nail ridging and May complicate hand dermatitis. dermatitis. discolouration. Oral Tongue, lips Macerated or red areas Infants, elderly, broad-spectrum Swab for Candida spp Topical and and buccal with white sticky plaques. antibiotics, diabetics, are subsidised. mucosa. immunosuppressed. Rarely, oral imidazole. Pityriasis Trunk and Multiple brown, white or Usually asymptomatic. Microscopy typical of Mild: disulfide, or versicolor proximal limbs. red, slightly flaky patches. Malassezia spp topical imidazole e.g. (resembles spaghetti and foaming solution, meatballs) ketoconazole shampoo. Often culture negative. Extensive: oral . is not effective. Tinea capitis Scalp. Young children. Scaling bald patches. M canis Oral antifungal e.g. terbinafine Adults. Black dots in follicles. T tonsurans for 4 weeks, repeat if mycology still positive. Tinea Trunk and Children – acute. Enlarging red plaques with elevated M canis Topical imidazole. corporis limbs. scaly border. Oral antifungal if extensive. Tinea Trunk and Adults – chronic. Enlarging red plaques with elevated T rubrum Topical imidazole. corporis limbs. scaly border. Check feet and nails Oral antifungal if extensive. Groin Adults. Expanding asymmetric plaque with T rubrum Topical imidazole. especially elevated scaly circinate border. Check feet and nails Oral antifungal if extensive. medial thigh. Differential includes erythrasma (pigmented) and other forms of intertrigo. Tinea pedis 4th/5th web Maceration and peeling. Athlete’s foot. T rubrum Consider non-fungal causes space. T interdigitale e.g. soft corn, psoriasis, E floccosum erythrasma. Instep. Clusters of blisters. May have athlete’s foot. T interdigitale Topical imidazole. Entire sole. ‘Moccasin’ dryness. May have athlete’s foot. T rubrum Oral antifungal if topical fails and culture positive.

17 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMMON FUNGAL INFECTIONS – scrape peeling or scaling skin for mycology CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS (Scrapings/clippings are essential) Tinea unguium Toenails esp. Ridged nail plate, Asymmetry, T rubrum Consider non-fungal causes esp. psoriasis. () great toenails, longitudinal lateral crumbling T interdigitale Only treat if clinically warranted and typical sometimes yellow streaks, nail. morphology or mycology is positive – oral fingernails. crumbling, subungual antifungal agent usually necessary for 2 months . (fingernails) or 3 to 4 months (toenails) and has 50% failure rate; re-infection is common. Nd:YAG laser treatment may be effective (expensive) but is as yet unproven. and ciclopirox olamine nail solutions are subsidised for diligent and persistent patients with limited distal fungal nail infection. Vulvovaginal Vulva + vagina. Acute or recurrent: Mainly affects High vaginal swab for Vaginal imidazole preparation. candidiasis itch, soreness, white young Candida albicans. Oral imidazole may be preferred if recurrent. sticky discharge. women. Swabs can be Hydrocortisone cream to vulva if itch persists after Irritant dermatitis of Itch is centred misleading. antifungal treatment. vulva (red, swollen). on the vagina.

18 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

ARTHROPODS CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS (if you know how) Head lice Scalp esp. behind More common in girls. Nits are hard to Dermoscopy of egg case to Several insecticides, e.g. pyrethroid ears, nape of neck. Itch, crusting, numerous remove from hair distinguish from hair cast. or malathion shampoo, benzyl egg cases (nits) on hair shaft. Egg cases alone are not alcohol and herbal preparations – all shafts, scurrying lice. Other children diagnostic of persisting have high failure rates. Repeat at 7 May cause secondary affected. infestation especially if more to 10 days. impetigo and than 1 cm from scalp. Comb wet hair frequently to remove lymphadenopathy. lice and eggs. Repeat treatment from time to time if adult lice identified. Additional cotrimoxazole for 2 weeks may be helpful for resistant cases if risk of adverse events can be justified. Machine-wash clothing and bed linen. Put toys, helmets etc. in airtight bag for 2 weeks. Insect bites Lower legs, Very itchy papules may Lesions appear in None. Covering clothing. Keep windows waistline, blister. crops, often closed (mosquitoes). anywhere. Persist for days to weeks. ‘breakfast, lunch and Treat cats, dogs and house for fleas tea’. (seek vet’s advice). Topical steroid promptly to itchy spot. Scabies Whole body except Burrows in web spaces Itchy +++ esp. at Dermoscopy of burrow (mite Careful application of insecticide scalp/face. and wrist creases. night. at skin surface has triangular from neck to toes, reapply if any Babies: prominent Excoriations everywhere. Polymorphic eruption ‘jet plane’ appearance). area washed, e.g. fingers. on palms and Papules in axillae/groins. (may resemble Extract mite for microscopy Treat all family members. soles, may involve eczema, urticaria, confirmation. Permethrin cream or lotion, wash off scalp/face. insect bites etc). after 8 to 14 hours. Penile papules. Repeat in 1 to 2 weeks as required. Several family members affected.

19 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

ECZEMA / DERMATITIS: ask about self and family re: asthma, eczema, hay fever (atopic triad) CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Infantile seborrhoeic Scalp, face, Relatively Age, site, lack of None. Reassurance – rash mostly clears dermatitis flexures asymptomatic red itch. spontaneously. Sometimes evolves into atopic (age 0 to 12 months) (axillae, groin, peeling areas. dermatitis. antecubital . Non-soap cleansers. fossa). Hydrocortisone 1% cream for flares. Imidazole cream may help. Dribble rash Cheeks and Relatively Contact site; Swabs for secondary Reassurance. Contact irritant under chin. asymptomatic, glazed, glazed infection. Non-soap cleansers. dermatitis dry, red plaques. appearance. Zinc cream or paste as barrier and emollient. (age 6 to 18 months) Associated with Hydrocortisone cream for flares. teething / dribble. Infantile/childhood Face, Acute flare-ups: Itch, typical Swabs for secondary Reduce exposure to irritants; non-soap wrists, symmetrical, red, sites, infection. cleansers. (starts after 3 months ankles, blistered plaques, lichenification. Food allergy tests if Emollients ++; of age, peaks at flexures or often infected. good grounds to Topical steroid creams (flexures and oozing 2 to 4 years, may anywhere. Chronic phase: dry suspect this. plaques) or ointments (dry plaques) for 10 to 21- persist) itchy skin, lichenified, day courses, and/or if >2 flares per month, Adult atopic Flexures plus excoriated plaques. weekend pulses – potency depends on dermatitis hands and site/severity face. +/- anti-staph. antibiotics +/- sedative antihistamines if sleep is disturbed. Pimecrolimus cream intermittently for chronic facial eczema to reduce use of topical steroids. Refer if severe, persistent or resistant for phototherapy or immunosuppressant (methotrexate, , azathioprine).

20 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

ECZEMA / DERMATITIS: ask about self and family re: asthma, eczema, hay fever (atopic triad) CONDITION LOCATION DESCRIPTION CLUES TO DIAGNOSIS INVESTIGATION MANAGEMENT Hand Dorsum +/- palmar Acute flare-ups: red, If unilateral, consider tinea Swabs for secondary Reduce exposure to irritants: dermatitis surface. swollen plaques or manuum and factors infection. non-soap cleansers, (mostly adults) Sometimes similar blisters. May be relevant to contact Scrapings if flaky, scaly or protective cotton-lined rubber on feet. impetiginised. dermatitis. unilateral. or vinyl gloves for wet /dirty May affect nails with Chronic: dry, fissured Refer for patch testing if tasks. irregular ridging, excoriated plaques. chronic or failing to respond Thick hand creams; pitting and Pompholyx: crops of to treatment. Potent or ultrapotent steroid discolouration. intensely itchy creams (vesicles) or ointments vesicles. (dry or fissured) for 2 to 4- week courses, and/or weekend pulses +/- anti-staph. antibiotics +/- sedative antihistamines if sleep is disturbed. Contact Any site, Well-demarcated red Affected area is exposed to Refer for patch testing if Depends on site (see hand irritant especially hands. plaques. Sometimes, an irritant (water, detergent, chronic or failing to respond dermatitis). dermatitis bizarre shapes. solvent, alkali, friction, cold, to treatment. Protect from irritant(s). Glazed or chafed and many other factors). Emollients. appearance. Mild topical steroids. Contact Any site. Asymmetrical acute or Odd-shaped plaques. Refer for patch testing if Depends on site (see hand allergic chronic presentation. Site in contact with , chronic, recurrent and/or dermatitis). dermatitis May blister perfume, rubber, hair dye, does not respond to Protect from irritant(s). (linear blisters suggest glue, creams (preservatives avoidance of specific contact Emollients. plant origin etc.) and many other factor(s). Potent topical steroids. e.g. toxicodendron). potential allergens. Short courses of systemic steroids, e.g. 40 mg for 5 to 10 days then reducing rapidly.

21 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

ECZEMA / DERMATITIS: ask about self and family re: asthma, eczema, hay fever (atopic triad) CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Nummular Lower legs Few to many, Shape of the lesion, Swabs for Non-soap cleansers. Emollients. (discoid) or dry or asymmetry of secondary infection. Potent or ultrapotent topical steroid ointments, sometimes required dermatitis anywhere. exudative, itchy, eruption. Scrapings if flaky, for months. May run round or oval scaly or unilateral. Oral anti-staphylococcal antibiotics for oozing plaques, sometimes along plaques. required for months. varicose More common Courses of systemic steroids, e.g. prednisone 40 mg daily for 2 to 4 veins. in men 40–60 weeks then reducing rapidly. years but may Refer for phototherapy or immune modulating agents. occur in women and children. Asteatotic Lower legs. Dry cracked skin Very dry skin. Thyroid function Non-soap cleansers. dermatitis with patchy red tests if Thick emollients especially after showering, bathing or swimming. (eczema areas, often dermatitis/dry skin Intermittent mild topical steroid ointment. craquelé) discoid. persists. Variable itch. Mostly affects elderly, sick, or people that bathe frequently. Gravitational One or Chronic dry skin Venous disease: Swabs for Non-soap cleansers. /stasis / both lower with flares of pigmentation, secondary infection. Thick emollients especially after bathing. venous legs. circumferential ulceration, Scrapings if flaky, Mild topical steroid ointment as required. eczema dermatitis (red, lipodermatosclerosis; scaly or unilateral. Courses of potent topical steroid ointment for 10 to 15 days. bumpy, crusted, may or may not have Doppler Encourage use of graduated compression hose. fissured). varicose veins. assessment if considering compression. Seborrhoeic Scalp, Dandruff, ill- Prominent bran-like Swabs for Education (chronic fluctuating dermatitis associated with malassezia dermatitis eyebrows, defined flaking scale; not much itch; secondary infection. irritating skin surface and activating innate immune reaction). upper and erythema. typical sites. Scrapings if losing Usually associated with dandruff. eyelids, Often flares with hair. When condition active, use of topical antifungal (e.g. ketoconazole nasolabial stress or in shampoo to wash face/scalp and/or ketoconazole or miconazole folds, chest certain climates. cream applied twice daily on the rash) and intermittent topical and steroid (usually hydrocortisone for a few days). axilla. 22 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

BENIGN SKIN LESIONS – symmetrical, well circumscribed, non-ulcerated and stable CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Angioma - spider Most often face and Red macule or Blanches with None required. Reassurance. Fine needle hands or anywhere. papule with ‘legs’. pressure. electrosurgery or refer for vascular laser / light treatment. Angioma - cherry Trunk or Red, blue, purple or Some blanching Dermoscopy confirms Reassurance. Cryotherapy, anywhere. almost black round with pressure. vascular colour and electrosurgery or refer for vascular papule 2 to 6 mm. globular structure. laser treatment (rarely required). Atypical naevus Anywhere. Unusual mole, e.g. Stable lesion. Dermoscopy, look for Explain that a naevus is benign. large, ill-defined, 3 asymmetry of Short-term (3 months) follow-up of flat to 4 colours, structure / colours. atypical naevi should include high irregular shape or Diagnostic excision quality clinical and dermatoscopic structure. with 2 mm clinical photography to assess change in margin if highly structure. suspicious of 5 or more atypical naevi significantly melanoma, or refer. increase risk of melanoma. Do not perform partial Check family members. Sun protection advice. biopsy. Corn / Pressure points, Thickened hard skin Pare down surface None. Relieve pressure; salicylic acid or usually on palms or with persistence of to reveal circular cream (heel balm, corn plaster etc). soles. markings. white core (corn) Regularly pumice or shave down using and no capillaries scalpel. (which are seen in warts) Dermal naevus Anywhere – face Skin coloured to Stable lesion or Dermoscopy helps Shave excision convenient but leaves common. dark brown firm slowly enlarging distinguish from BCC. scar and pigment may recur. Always papule with smooth over decades. obtain histology. or papillomatous surface. May be hairy. Lower limbs mostly, Brownish indurated Dimples on lateral Often has central Reassurance. (histiocytoma) upper limbs papule. Often compression. white area on Cryotherapy may flatten the lesion. sometimes, and initiated by insect dermoscopy. Discourage excision unless the patient less often bite or minor Excise for histology if prefers to have a scar. elsewhere. trauma. actively growing. 23 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

BENIGN SKIN LESIONS – symmetrical, well circumscribed, non-ulcerated and stable CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Epidermoid Face, neck, trunk. Mobile nodule filled with Central follicular If inflamed, swab for Reassurance; most cysts are best left cyst Firm nodules on keratin. punctum (use Staph aureus. alone. scalp are pilar cysts. May rupture and become magnification to see Non-inflamed: incision, express keratinous inflamed but is rarely this). Pilar cysts do contents and pull or cut out sac. infected. not have a punctum. Inflamed (seldom due to infection): excision biopsy when has settled (4 to 6 weeks). Amoxiclav for painful fluctuant cyst + drain purulent material using #11 blade. Culture may include anaerobes. / Sun exposed or One or numerous, small Stable lesion of If clinically suspicious Only follow up when lesion has low previously sunburned to large, uniform tan single colour. for melanoma refer or suspicion of malignancy. Short-term (3 sites. macules. diagnostic excision months) follow-up of lentigo should include with 2-mm clinical high quality clinical and dermatoscopic margin. Do not do photography to assess change in partial biopsy. structure. Sun protection. Anti-aging creams may fade them. Light cryotherapy, IPL or laser ablation, but only if there is no possibility of melanoma. Milia Eyelids, cheeks or 2 to 3 mm white papules, Tiny firm balls without None. Reassurance. anywhere. filled with keratin. follicular opening. Prick and express contents. Mole Anywhere, Pink to dark brown well- Most arise during Dermoscopy reveals Reassurance. (common often most numerous defined macule, childhood or symmetrical structure If removal desired, then full excision melanocytic on upper arms or papule or plaque, adolescence. +/- uniform brown biopsy with histology is mandatory. naevus) back. 2 to 6 mm diameter, Stable lesion. globules or pigment Should not be treated by cryotherapy or 1 to 2 colours. network. If in doubt, laser. observe 3 to 6 months Full skin examination appropriate if many with photographs, or moles, atypical moles or other risks / excise. concerns relating to melanoma. Other benign Anywhere. There are numerous Acquired lesions are If in doubt, biopsy. Reassurance. skin lesions congenital and acquired usually small and If in doubt, photograph to observe, biopsy, lesions of epidermal and stable. excise or refer. dermal origin.

24 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

BENIGN SKIN LESIONS – symmetrical, well circumscribed, non-ulcerated and stable CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Pyogenic Lips, fingers or Bleeding soft nodule Common in children If present for weeks, Reassurance. granuloma any site of minor appears in days to and during excise to rule out If bleeding, excise or shave, curette and trauma. weeks. pregnancy. amelanotic electrosurgery (always with histology). melanoma.* Sebaceous Forehead and Yellowish or skin Central pit, may Dermoscopy reveals Reassurance. hyperplasia cheeks. coloured papule. have uniform ‘crown’ yellowish lobules Electrosurgery (but it may not be of blood vessels on around central effective). magnification. follicle. Seborrhoeic Anywhere, Few to numerous. Stuck-on Dermoscopy Reassurance. keratosis especially under White, yellow, grey, tan, appearance. typically reveals Cryotherapy to thin lesions. breasts. brown or black or Peel off scaly top. irregular structure Electrosurgery/curettage to thick lesions. several colours. with milia-like cysts, Histology if there is the slightest doubt. Warty or greasy plaque. comedo-like Sometimes itchy. openings, fissures and ridges. Excision biopsy if suspicious of melanoma.* Axillae, neck, groin. Pedunculated skin- Clustered in typical None needed. Reassurance. coloured soft papules. sites. Cryotherapy to small lesions. Electrosurgery / scissor snip for larger ones. Telangiectasia Anywhere. Dilated capillaries (red) Blanche with None required. Reassurance. (capillaries) or or venules (blue). pressure. Refer for vascular laser treatment (face) venulectasia or sclerotherapy (legs). (venules)

25 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

SKIN CANCERS - asymmetrical, irregular, may be ulcerated and growing or changing. Educate about sun protection, risk of skin cancer, self skin examination and when to seek help. CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Basal cell Face, Skin-coloured or Slowly enlarging. Dermoscopy often Excision biopsy with 3-4 mm margin. Mid- carcinoma: neck or pink pearly papule Bleeds easily, fails reveals irregular facial lesions should be referred to skilled nodulocystic anywhere. or nodule, central to heal, not painful. structure, peripheral surgeon, as incomplete excision is ulceration, irregular. blue-grey areas and common and difficult/expensive to rectify. branched red lines Curette and cautery for small well-defined (telangiectasia). surface lesions. Follow up. No place for Biopsy cryotherapy or topical therapy. (shave or punch). Basal cell Trunk, Slowly enlarging Bleeds easily, fails Dermoscopy often Cryotherapy (not face) requires carcinoma: limbs or pink dry plaque, to resolve with reveals ulceration prolonged and / or double freeze with superficial anywhere. may ulcerate; topical steroid and diffuse reddish- 3 mm margin, and careful follow-up. often multiple, cream. blue colour. Curette and cautery/diathermy for small irregular. Minimal scale. Biopsy well-defined surface lesions. (shave or punch). Excision biopsy for small lesions with 3 to 4 mm margin (pathologist will report margins). Refer facial lesions. Imiquimod may clear 85% if applied 5x/week for 6 to 16 weeks. Follow up. Fluorouracil is rarely effective. Squamous cell Sun damaged sites In situ: one or many History of very slow Dermoscopy reveals Cryotherapy. carcinoma especially scalp, slowly-growing red enlargement. irregular shape, Shave, curette, electrosurgery. ears, face, hands, scaly plaques. Irregular scale. scale and coiled Fluorouracil bd for 6 weeks (interrupt forearms, lower blood vessels. treatment if excessive reaction). legs. Biopsy Imiquimod 5x/week for 6 weeks or longer. (shave or punch). Refer for . SCC in situ frequently recurs, whatever treatment is used. Invasive: tender Firm nodule under Biopsy if diagnosis Freeze firmly or twice if < 5 mm diameter; papule or nodule. solar keratosis. uncertain (shave or follow up. Grows over weeks to Tender. punch). Excision biopsy. months.

26 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

SKIN CANCERS - asymmetrical, irregular, may be ulcerated and growing or changing. Educate about sun protection, risk of skin cancer, self skin examination and when to seek help. CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Keratoacanthoma Usually sun exposed Keratoacanthoma: Volcano-like. Biopsy if diagnosis Freeze firmly or twice if < 5 mm site Rapid growth over uncertain diameter; follow up. days to weeks. (shave or punch). Shave, curette, electrosurgery. Excision biopsy. Do not expect natural resolution – many clinically diagnosed KAs are SCCs pathologically. Melanoma Anywhere – 40% Superficial ABCDE/Glasgow Dermoscopy reveals Excision biopsy with 2 to 3 mm clinical trunk (males), spreading; mostly checklist.* disordered margin. lower legs (females). horizontal growth, Grows over 1 to 5 structure/colour Punch and shave are initially in situ. years. See page 32 (chaos and clues). contraindicated. Face and neck. ABCDE/Glasgow Dermoscopy reveals Long incisional biopsy through large flat (in situ). checklist.* See page irregular rhomboid lesion may be acceptable. Lentigo maligna 32 pigment network Provide pathologist with a diagram or melanoma In situ phase may and grey dots. photograph to indicate clinical areas of (invasive). persist 1 to 30 concern. years. If excision is difficult, refer to Anywhere de novo, or Nodular. Symmetrical, single Careful dermoscopy dermatologist (best at clinical and within pre-existing flat colour (incl. red). reveals irregular dermoscopic diagnosis), plastic surgeon, melanoma. Grows over 3 to 2 structures/colour. or if unavailable, general surgeon. months. In borderline flat melanocytic lesions, it Palms, soles, nails. Acral lentiginous. ABCDE/Glasgow Typically has may be reasonable to photograph and checklist*. See page parallel ridge pattern review in 3 months (dermoscopy images 32 and irregular are required). Grows over 1 to 5 structure on Excise if change observed. years. dermoscopy. Do not watch an undiagnosed enlarging nodule in an adult – cut it out or refer. Ulcerated, Anywhere, Irregular disordered Biopsy Depends on histological diagnosis. bleeding or most often sun appearance (shave or punch). enlarging lesion exposed sites. suggests malignancy.

27 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

EMERGENCY DERMATOLOGY – conditions that require urgent referral and/or treatment CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Meningococcal Extremities. Purpuric spots in an Neck stiffness, Don’t wait. Penicillin and IV fluids immediately. disease acutely unwell patient. , Blood culture, Provide oxygen. Blood culture where fever, hypotension, lumbar puncture. possible. tachycardia, absence Arrange emergency evaluation and of respiratory admission to intensive care unit. symptoms, confusion. Anaphylaxis and Wealing is Acute urticaria +/- Swelling of tongue or Skin prick testing in Call for help – assess need for CPR. anaphylactoid widespread. angioedema with throat. Hypotension, safe environment. Administer oxygen. reactions systemic features tachycardia, Supervised IM adrenaline 0.5 ml 1:1000 – repeat in 5 following exposure to bronchospasm and challenge testing by minutes if necessary. allergen collapse. expert allergist. Rapid IV infusion of colloid or normal saline. e.g. food, drug, sting Oral or IV promethazine 25-50 mg. – 30 % are of unknown Then hydrocortisone 250 mg IV. cause. Observe for 6 to 12 hours. Patient should wear MedicAlert® bracelet and avoid beta-blockers. Train patient to carry antihistamine and in use of injectable adrenaline. Immunotherapy for inhalant allergies and bee or wasp stings. Staphylococcal Often flexural but with superficial Rash often preceded Skin swabs for Anti-staphylococcal antibiotics (usually scalded skin may be blistering and . by sore throat or Staph aureus flucloxacillin) and supportive care. generalised. Rarely may affect conjunctivitis. culture and adults with renal failure. sensitivity. Necrotising Anywhere, May follow surgery or Affected tissue Skin swabs and A surgical emergency – necrotic tissue fasciitis but lower limb most arise spontaneously. becomes blood/ tissue culture. must be thoroughly debrided rapidly. common. Local severe pain and anaesthetic. Very Group A Administer broad-spectrum antibiotics IV systemic toxicity. rapid deterioration streptococcus or immediately and start IV fluids. Advancing erythema, may occur. polymicrobial. Patient should be managed in intensive painless ulcers and Full haematological care unit. black necrotic eschar. and biochemical NSAIDs are contraindicated. screen.

28 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

EMERGENCY DERMATOLOGY – conditions that require urgent referral and/or treatment CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Acute Lower limbs Palpable purpura, Crops of purple Consider Henoch Refer to dermatologist ( < 3 days) for hypersensitivity predominantly. sometimes with spots and blisters. Schonlein purpura if management. ulceration, often abdominal pain and Systemic steroids are not always with and arthritis. appropriate. mild systemic Throat swabs, Advice rest and leg elevation. symptoms. haematological and Treat underlying cause if identified. biochemical screen. Skin biopsy. Exfoliative 90% or more of the Generalised “The red man”. Blood count, renal Discontinue all unnecessary dermatitis skin surface. erythema and and liver function. . Refer for hospital oedema; often with Internal organ admission to monitor fluid balance and serous ooze, and an dysfunction may body temperature; cool and moisturise unpleasant smell; indicate drug inflamed skin with wet dressings, scaling 2 to 6 days hypersensitivity emollients and mild topical steroids. after the onset of syndrome. Antibiotics if secondary infection is erythema, as fine present. Antihistamines for severe itch. flakes or large Use of systemic steroids depends on sheets; itch is cause and effect of initial therapy – variable, often consult dermatologist. severe. Immunobullous Mucosal or skin Erosions and Unexplained Skin biopsy of a Refer to a dermatologist acutely for surfaces. blisters in a patient blistering. new, preferably management, which will require accurate that is otherwise intact, blister diagnosis, work-up and, often, systemic well. essential. steroids plus immunosuppressive Skin antibodies. agents. Skin swabs for bacterial and viral culture.

29 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

EMERGENCY DERMATOLOGY – conditions that require urgent referral and/or treatment CONDITION LOCATION DESCRIPTION CLUES TO INVESTIGATION MANAGEMENT DIAGNOSIS Generalised Any part of body, Dry, fiery red and Often, patient has Calcium to check for Consider admission if unwell or pustular psoriasis but often worst in tender plaques with recently finished a low levels, low pustulation is extensive. flexures. fever and malaise. course of systemic plasma albumin and Bland compresses restore electrolyte Within hours crops steroids. zinc, high ESR, imbalance; mild topical steroid cream of sterile pustules May or may not raised neutrophil may relieve discomfort. appear especially in have preceding count, reduced If admission is not required, refer to flexures. May plaque psoriasis. lymphocyte count dermatologist acutely to consider coalesce to form and raised lactate acitretin, methotrexate. lakes of pus, which levels. Sometimes it is necessary to restart then dry and peel to Skin swabs for corticosteroids, usually temporarily, but if leave behind a bacteria, yeasts and so, withdrawal must be extremely slow. glazed, smooth viral culture. surface on which new crops of pustules may appear. Toxic epidermal Mucosal and skin Painful erosions, Painful blistering in Skin swabs for Discontinue responsible necrolysis surfaces. blisters and a sick patient. Staph aureus immediately (sulphonamides, cutaneous necrosis culture and anticonvulsants, NSAIDs, allopurinol). with systemic sensitivity. Admit to intensive care or burns unit for symptoms: fever, Full haematological IV fluids and supportive care. malaise, collapse. and biochemical Do NOT prescribe systemic steroids screen. unless approved by dermatologist. Skin biopsy to In some cases, steroids, ciclosporin confirm diagnosis. and/or IV immunoglobulin may be used in hospital.

30 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

CLINICAL DIAGNOSIS OF MELANOMA

ABCDEFG of Melanoma A: Asymmetry of shape and pigment pattern B: Well-defined irregular border C: Variation in colour, often with a red halo D: Diameter over 6 mm (but it is possible to diagnose smaller ) Different (from the patient’s other skin lesions) E: Evolution (change in size, colour, shape, surface over several months), or Elevated (when accompanied by ‘F’ and ‘G’) F: Firm G: Growing

Glasgow 7-point checklist Major features  Change in size  Irregular shape  Irregular colour Minor features  Diameter >7 mm  Inflammation  Oozing  Change in sensation

Colours include red, blue, white (regression), tan, brown, black and blue; the greater the number of colours the deeper the lesion. Training in dermoscopy is very helpful for identifying early melanoma and benign lesions. 31 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

PRINCIPLES OF DIAGNOSIS  Take a history (don’t just look at the lesion): onset, duration, affected sites, and exacerbating and relieving factors.  Ask specific skin symptoms e.g. itch, soreness, why it’s of concern.  Examine all of skin including mucosal surfaces where relevant.  Consider the location.  If it’s oozy or crusted, consider primary or secondary bacterial infection.  If it’s scaly, do a fungal scraping.

GENERAL PRINCIPLES OF TREATMENT  Patient education! Many skin diseases persist whatever you do – provide written information about the condition.  Print out the relevant page from http://www.dermnetnz.org/ and give it to the patient.  Many failures of therapy are due to wrong vehicle or infrequent administration or inadequate quantities.  Prescribe ointments for dry lesions, creams for wet lesions, sprays, gels or lotions for hairy areas.  A single whole body application requires 10 g for a baby and 30 g for an adult; a 10-day course requires up to 300 g.  One hand uses 0.5 g per application; 30 g is adequate for hand dermatitis for one month.  Prescribe 500 g pot of emollient expecting 2 pots to be used each month in extensive eczema.  Generally start with topical treatment before oral, depending on severity and acuity of condition.  If treatment (or masterly inactivity) not working, then reconsider diagnosis and reconsider treatment process.  If still having problems, obtain second opinion and/or biopsy.

32 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

PRINCIPLES OF TREATMENT FOR ECZEMA

 Reduce exposure to irritants and known allergens. Suggest or prescribe soap substitutes, usually aqueous cream or emulsifying ointment (for very dry skin) or pine tar solution (for itch). There are many suitable bar, cream and gel non-soap cleansers.  Explain the itch-scratch cycle. Encourage patients to put an ice pack or cold flannel on the itchy area and apply a moisturising cream rather than scratch.  Explain barrier function of skin and barrier defects causing eczema and exacerbated by eczema.  Moisturise the skin (see page 38). The choice depends on how dry the skin is and patient preference. Suitable moisturisers include: fatty cream, cetomacrogol/non-ionic cream base and sorbolene cream. Urea-based products are best for /xerosis (these may sting and irritate in atopic dermatitis). Emollient wool fat or mineral oil lotions are soothing and quick to apply but not adequate if the skin is very dry. Oatmeal preparations are often well tolerated and popular but are not subsidised on prescription. Aqueous cream (with SLS) can irritate and should not be used as a leave-on moisturiser. Topical corticosteroids should be used for flare-ups, i.e. courses of 5 days to 4 weeks depending on location and severity. Hydrocortisone 1% cream is safe on any part of the body except eyelids. Medium potency steroids (group 2 and 3) are appropriate for trunk and limbs but ultrapotent steroids (group 4) are required for palms and soles (see page 35 and 36).  If skin is not improving and there are oozing or crusted plaques, consider antibacterial treatment. Topical antiseptics (e.g. hydrogen peroxide cream) may help minor localised infections but prescribe oral antistaphylococcal antibiotics (flucloxacillin, erythromycin or cephalexin) for more widespread infection. If infection persists, swab for methicillin resistance (MRSA).

IMMUNE MODIFYING AGENTS AS A TREATMENT FOR ECZEMA Pimecrolimus cream and ointment are calcineurin inhibitors developed specifically to treat inflammatory skin conditions, particularly atopic dermatitis. Topical tacrolimus is not yet registered in New Zealand and is very expensive (2016). Minimise sun exposure and only use the calcineurin inhibitors when they have definite advantages over topical steroids (e.g. when there is concern about the potential for topical corticosteroids to cause skin thinning on face and flexures).

33 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

PRINCIPLES OF MANAGEMENT OF PSORIASIS  Classify as acute guttate or pustular psoriasis or chronic plaque psoriasis; localised (e.g. scalp, flexures, extensor surfaces) or generalised; early onset <40 years or late onset > 40 years; small or large plaque.  Estimate severity by body surface area (>10% is severe), PASI (Psoriasis Area and Severity Index) score ( > 10 is severe) and/or DLQI (Dermatology Life Quality Index) ( > 10 is severe).  Patients with severe psoriasis should be under the care of a dermatologist.  Patients with psoriasis have a systemic disease with increased risk of arthritis and cardiovascular disease.  Large plaque psoriasis is strongly associated with metabolic syndrome (obesity, type 2 diabetes, dyslipidaemia, hypertension) and high alcohol intake. It is aggravated by smoking.  Assess, advise and treat patient for concomitant diseases.

TREATMENT FOR PSORIASIS Topical treatment for everyone.  Encourage use of emollients to relieve itch and dryness anywhere anytime.  Prescribe ointment (extensor plaques), cream (flexures, ears) and/or solution (scalp).  For trunk and limbs, use Daivobet® is a once-daily combination of betamethasone dipropionate and calcipotriol as ointment (30 g) or gel (60 g)’.Used for 4-week courses for trunk and limbs/scalp followed by 4-week break.  Use a group 1 to 2 topical steroid applied accurately at night for up to 4 weeks then pulsed at weekends for face and flexures. Primecrolimus cream is an alternative, applied twice daily as required.  Add coal tar ointment or gel (for scalp, apply Coco-Scalp® ointment or similar an hour prior to shampooing with tar shampoo).

Refer guttate and generalised small plaque psoriasis for phototherapy: (UV)B, usually narrowband (311 mm), 3 times weekly for 20 to 40 treatments.

Refer severe psoriasis for systemic agent:  Methotrexate 15–30 mg once weekly (monitor with CBC, LFT, creatinine, P3NP procollagen and if available, transient elastography scan).  Ciclosporin 2.5–5 mg/kg/day for short-term flare (monitor renal function and blood pressure; reduce dose if 30% rise in creatinine and/or hypertension). Treat hypertension.  Acitretin 10–50 mg daily; requires Special Authority application, (teratogen so not prescribed in women during childbearing years, mucocutaneous side effects are poorly tolerated; monitor CBC, LFT and especially lipids).  Biologics: etanercept, infliximab, adalimumab, secukinumab funded for severe psoriasis on Special Authority application by dermatologist. 34 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

TOPICAL CORTICOSTEROIDS *Fully subsidised (December 2016)

Group 1 - Mild Drug Application type Hydrocortisone 0.5% Cream (15 g, 30 g) – available OTC, Pharmacy Only (15 g, 30 g) *Hydrocortisone 1% Cream (30 g, 500 g); Lotion (250 ml) prescription or OTC, Restricted (15 g, 30 g)

Group 2 - Moderate Drug Application type Cream 30 g * Cream (100 g); ointment (100 g)

Group 3 - Potent Drug Application type * Cream (50 g); ointment (50 g); scalp application/solution (100 ml); lotion (50 ml) *Betamethasone dipropionate Cream (15 g, 50 g); ointment (15 g, 50 g) valerate Cream (50 g); fatty ointment (50 g) *Hydrocortisone-17-butyrate Lipocream (30 g, 100 g); ointment (100 g); scalp lotion (100 ml); milky emulsion (100 ml) * aceponate Cream (15 g); ointment (15 g) * furoate Cream (15 g, 50 g); ointment (15 g, 50 g); lotion (30 ml)

Group 4 – Very potent Drug Application type *Betamethasone dipropionate OV (optimised vehicle) Cream (30 g); ointment (30 g) * propionate Cream (30 g); ointment (30 g); scalp application (30 ml)

35 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

COMBINATION TOPICAL CORTICOSTEROID + ANTIMICROBIAL

For short-term ( <14 days) use in angular cheilitis, non-specific intertrigo, localised infected eczema. Inappropriate if a single agent will work. Drug Application type Betamethasone valerate + clioquinol Cream (15 g) Betamethasone valerate + fusidic acid Cream (15 g) *Hydrocortisone + + neomycin sulphate Cream (15 g); ointment (15 g) *Hydrocortisone + miconazole 1% Cream (15 g) prescription or OTC, Restricted 1% (10 g, 15 g, 30 g); Pharmacy Only 0.5% (15 g, 30 g) Hydrocortisone + clotrimazole 1% Cream (15 g, 20 g, 30 g) Triamcinolone acetonide + gramicidin + neomycin Cream (15 g) sulphate and

SAFETY ISSUES WITH TOPICAL CORTICOSTEROIDS:  Avoid potent topical steroids on the face and in skin folds i.e. groin, axilla and under breasts (group 2, 3 or 4) – they can cause , striae and telangiectasia. Hydrocortisone is first choice. Only use potent corticosteroids for short periods (a few days and up to two weeks) under strict supervision.  Occlusion (i.e. under cling film) increases the efficacy and side effects of topical steroids.  Neomycin is potentially sensitising, so mixtures that contain this should be used with caution. Combinations of miconazole + hydrocortisone are suitable for or intertrigo.  Groups 2, 3 or 4 steroids can be safely used on the scalp.  is a potent steroid (group 3).  Group 4 steroids are very potent but may be necessary for chronic thickened skin e.g. on hands and feet.  Prescribe as daily application for 2 to 4 weeks only, then if required, 2 days per week (weekend pulses). Long term use of topical steroids damages the skin barrier and may prevent full recovery from dermatitis.  Be aware of tachyphylaxis (reduced response with repeated applications). If this occurs, you need to stop the topical steroid for at least 2 weeks.  Hydrocortisone 1% is safe everywhere except the eyelids, where it should only be applied for a few days now and then (thins skin, may result in cataracts and glaucoma). For long-term eyelid condition, consider pimecrolimus cream.  Avoid intralesional steroid unless trained in injection technique.

36 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

EMOLLIENTS Numerous non-soap cleansers, moisturisers (adding water) / emollients (adding grease) are available OTC. A number of bland products suitable for patients with skin disease and made by reputable manufacturers are available. Patients may have strong preferences; encourage them to try several products and to apply them frequently. Avoid formulations that sound complicated or have multiple plant-derived ingredients as these are often irritating. Costly products are not necessarily better than cheap ones. However, ceramide moisturisers and others designed to improve barrier properties in atopics may be recommended to those that can afford them.

PHARMAC subsidises the following *Fully subsidised (February 2019)

Name Ingredients Comments *Aqueous cream (SLS-free) Emulsifying wax 9 g (cetostearyl alcohol, sodium lauryl Traditional aqueous cream with SLS (500 g) sulfate), white soft paraffin 10 g, liquid paraffin 6 g; should only be used as soap substitute. phenoxyethanol 1 g; boiled and cooled purified water to 100 g. *Cetomacrogol cream Cetomacrogol emulsifying wax 15%, liquid paraffin, white General purpose. (500 g) soft paraffin, chlorocresol, propylene glycol. *Dimethicone 5%, 10% cream (500 ml), Dimeticone, hydroxybenzoates. Barrier cream, e.g. for hand dermatitis. 4% lotion (200 ml) Head lice (4% lotion) *Sorbolene with 10% glycerine (500 Cetomacrogol aqueous, glycerol 10%. Pump pack is convenient and reduces ml/g, 1000 ml [1 kg]) infection concern. General purpose. *Zinc and castor oil ointment (500 g) Zinc oxide 7.5%, castor oil 50%, arachis oil, white Barrier cream, especially useful for napkin beeswax, cetostearyl alcohol. dermatitis. *Oil in water fatty emulsion cream cetostearyl alcohol + paraffin liquid + paraffin soft white Thicker general-purpose cream, suitable for (500 g) hands, lower legs. *Urea cream 10% Useful for scale and very dry skin but can (100 g) sting e.g. in atopic eczema. Wool fat with mineral oil lotion Wool fat/lanolin 0.56%, mineral oil 15.2%. General purpose but may not be greasy (250 ml, 1000 ml) enough for eczematous skin. *Emulsifying ointment Emulsifying wax 30 %, white soft paraffin 50 %, liquid Well tolerated by most (500 g) paraffin 20 %. Soft white paraffin Used in combination with a dermatological galenicals Subsidised only if used as a base e.g. for (2.5 kg, 500 g) hydrocortisone 1% ointment. *Liquid paraffin 50% with white soft General purpose thick emollient for very dry paraffin 50% (500 ml) skin

37 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus. Management of Common Skin Conditions In General Practice

Dermatological bases: • Aqueous cream • Cetomacrogol cream BP • Collodion flexible • Emulsifying ointment BP • Hydrocortisone with wool fat and mineral oil lotion • Oil in water emulsion • Urea cream 10% • White soft paraffin • Wool fat with mineral oil lotion • Zinc and castor oil ointment BP • Proprietary Topical Corticosteroid-Plain preparations Dermatological galenical/s will only be subsidised when added to a dermatological base. • Coal tar solution - up to 10% • Hydrocortisone powder - up to 5% • Menthol crystals • Salicylic acid powder • Sulphur precipitated powder

ANTIPRURITICS

Menthol 0.5-1% is subsidised if the crystals are in combination with a dermatological base (emollient) or topical corticosteroid. It cools and relieves itch short-term, but may not be tolerated because of stinging and burning. Crotamiton cream 10% 20 g can be used to soothe itchy spots e.g. insect bites. Calamine cream/lotion reduces itch but may dry skin and aggravate dermatitis.

KERATOLYTICS

Salicylic acid 0.5 - 10% can be added as a powder to the dermatogical bases listed above to soften localised scaly conditions. Coal tar solution (up to 10%) and precipitated sulphur can be added, e.g. to aqueous cream as a wash-off preparation for scalp conditions.

New Zealand approved datasheets are the official source of information for these prescription medicines, including approved uses and risk information. Sources of further information include:  New Zealand Formulary  New Zealand Universal List of Medicines  Individual New Zealand datasheets on the Medsafe website  PHARMAC Schedule.

38 © Arroll, Fishman & Oakley, Department of General Practice and Primary Health Care, University of Auckland, Tamaki Campus.